A Health Systems Approach to Addressing Pre-diabetes and Hypertension in WV

Submission Date: June 2018

Entry Type: Case Study

State/Territory Submitted on the Behalf of: West Virginia

States/Territories Involved: West Virginia

Funding Source: CDC

CDC Funding:

Yes

CDC Funding (Specified):

(1305) State Public Health

Domain Addressed:

Community-Clinical Linkages, Health Systems Strategies

Public Health Issue:

West Virginia has the highest prevalence of high blood pressure in the nation, at 42.7%. Also, almost 10% of the state’s adults have prediabetes, a precursor for developing type 2 diabetes and other serious health problems, including heart disease and stroke.

Given the severity of the chronic disease burden in the state, effectively engaging a continuum of health systems partners is essential.

Project Objectives:

To develop a systems-based approach to working with local health departments and primary care was initiated in 2013 to better identify and address prediabetes and hypertension with the goal of cost-effective, early detection for reduced morbidity and mortality.

Program Action:

The Centers for Disease Control and Prevention Prediabetes Screening Tool was used to quickly determine pre-diabetes risk among clinic patients.

The Million Hearts Stoplight Card afforded an opportunity to categorize blood pressure results into safe, cautionary, or critical values for care and follow-up while also educating patients on their blood pressure results.

A patient survey developed by the West Virginia Bureau for Public Health, Division of Heath Promotion and Chronic Disease, was completed in tandem by health department staff and patients for increased patient self-management goal setting and follow-through with primary care on priority issues.

Impact/Accomplishments:

This effort achieved a 3.71 per participant return on investment on diabetes prevention and hypertension control among sampled participants.

The work demonstrates the following:

• Increased patient empowerment and health literacy are essential in better addressing patient’s health care concerns;
• Building a closer-knit system of care in which local health and primary care work collaboratively can improve care for high-need, high-risk patients; and
• Enhanced systems of care for West Virginia require a sustained approach to chronic disease prevention and control.

 

Challenges/Lessons Learned:

Through this effort, West Virginia public health leaders and stakeholders have demonstrated essential capacity building and longer-term vision for achieving decreased burden of chronic disease in the state. The synergy established across primary care, community, public health, and state-based organizations highlights local-level leadership, capacity building, and heightened sense of team-based care spanning primary care and community-based organizations.

Collectively, challenges in identifying high-risk, high-need patients, ensuring those individuals are linked with appropriate care and education, and ensuring that essential data are shared appropriately across partners have been addressed head-on in the form of clinic/community linkages designed to support key public health priorities.

Next Steps:

Partnerships established and strengthened in this effort are being moved forward in West Virginia’s application to the Centers for Disease Control and Prevention’s 1815 grant opportunity, designed to bring collaborative efforts such as this to a higher level of functionality and sustainability.

Program Areas:

Diabetes, Heart Disease and Stroke

State Contact Information:

WV
Adam Baus (abaus@hsc.wvu.edu) / DeFrehn Erikah L (Erikah.L.DeFrehn@wv.gov)
abaus@hsc.wvu.edu

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